Surgical Protocol Shows Promise as a New Standard of Care for Oncology Surgery

ANAHEIM, CA — The enhanced recovery after surgery (ERAS) protocol has revolutionized the care of the surgical oncology patient, resulting in shorter length of hospital stay by 30% to 50% and similar reductions in complications, reducing readmissions and costs. Implementation of this program was described in a presentation at the Oncology Nursing Society (ONS) 44th Annual Congress.

Cameron Carr, ADN, RN, discussed the experiences at Duke Raleigh Hospital in North Carolina, in initiating the ERAS protocol. The goal of the researchers was to implement an evidence-based clinical pathway for surgical oncology to improve outcomes in urology oncology procedures.

Patients with prostate or renal cell cancer were spending long periods of time in the hospital resulting in high rates of readmissions via the emergency department for infections and pain management. The medical/surgical oncology unit included in the study had 29 intermediate to step-down beds, which handled patients admitted for chemotherapy, surgery, and palliative care and the average length of stay was 5 to 11 days.

ERAS is a multimodal, integrated, multidisciplinary approach to care of the surgical patient that utilizes evidence-based protocols to standardize care, improve outcomes, and lower health care costs. Its protocols minimize surgical trauma and postoperative pain, reduce complications, improve outcomes, and decrease length of hospital stay.

Components of ERAS care include changing the overnight fasting to a carbohydrate drink 2 hours before surgery; minimally invasive approaches rather than large incisions; IV fluid management for individual balance rather than large volumes of fluids; avoiding the use or early removal of drains and tubes; early mobilization; and early resumption of food and drinks on the operative day.

The researchers offered educational sessions on the practical knowledge necessary to follow the ERAS protocol to members of the multidisciplinary team, including nurses, doctors, dietitians, and physical/occupational therapists.

Implementation of the protocol began in Fall 2017. Outcomes metrics for prostatectomy include 36% improvement in length of stay (LOS) index, 100% improvement in 30-day readmission rate (3.6% in fiscal year (FY)2018 to 0% in FY2019), and 46% improvement in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) overall rating. For nephrectomy, ERAS resulted in a 16% decline in LOS index, a flat readmission rate (0% in FY2018 and FY2019), and a 33% decline in HCAHPS overall rating.

The transition to ERAS in this surgical oncology population was easier because the ERAS protocol is used in other surgical populations, explained Ms Carr. “We will soon be implementing ERAS for our breast reconstruction patients with free flaps.” This is a new surgery for the unit, but the staff anticipate a successful rollout based on the current use of the ERAS principles.

Reference

Carr C. Quick ticket home: implementation of enhanced recovery after surgery. Oral presentation at: ONS 44th Annual Congress; April 11-14, 2019; Anaheim, CA.